2

Venous Diseases

Anatomy:

• Superficial and deep systems

All are valved

• Important perforators

• Sinusoids.

Anatomy:

Venous pressure on standing 100 mmHg

Single calf muscle contraction empties 60% of pooled blood


Ambulatory venous
pressure 40 mmHg
Physiology:

According to Virchow’s Triad

Changes in the vessel wall (endothelial damage);
Changes in the blood flow (stasis);
Changes in the blood composition (hypercoagulability).

Etiology:

• Deep Vein Thrombosis (DVT)

Risk factors:

Patients factors:
• Age
• Obesity
• Varicose veins
• Immobility
• Pregnancy
• Puerperium
• Oral contraceptive pills
• Previous deep vein thrombosis or pulmonary embolism


• Trauma or surgery,
• Malignancy,
• Heart failure
• Recent myocardial infarction
• Paralysis of lower limb(s)
• Infection
• Inflammatory bowel disease
• Nephrotic syndrome
• Polycythaemia
• Paraproteinaemia

Occlusive thrombus

Pathology:

Non occlusive thrombus

• embolism
•

• Complete resolution of thrombus

• Incomplete resolution  Post phlebotic syndrome and chronic venous insufficiency
• Organization of thrombus
• Embolization.
Fate of DVT:

Pain and swelling

Bilateral in 30%

Asymptomatic

Chest pain, dyspnea and hemoptysis (pulmonary embolism)

Phlegmasia alba dolens (white leg)

Phlegmasia cerulea dolens
Clinical presentation:

• Pitting oedema of the ankle,

• Dilated surface veins,
• A larger stiff calf
• Tenderness
• Hotness
• Homans’ sign – resistance (not pain) of the calf muscles to forcible dorsiflexion
• A low-grade pyrexia may be present
• Signs of pulmonary embolism or pulmonary hypertension
On examination:

• Duplex ultrasound

• Venography
• D-dimer
• If pulmonary embolism suspected:
• Ventilation / perfusion scan
• CT scan
• Pulmonary angiography
Inestigations:


• Ruptured Baker’s cyst,
• A calf muscle haematoma,
• A ruptured plantaris muscle,
• Thrombosed popliteal aneurysm
• Arterial ischemia
Differential diagnosis:

Low risk: young, with minor illnesses, who are to undergo operations lasting 30 min or less.

Moderate risk: over 40 or with a debilitating illness who are to undergo major surgery.

High risk: over 40 who have serious medical conditions, or undergoing major surgery with an additional risk factor.
Prophylaxis:

Mechanical methods:

• graduated elastic compression stockings
• external pneumatic compression
• passive foot movement (foot paddling machine)
• simple limb elevation
Pharmaceutical methods:
• low molecular weight heparin
• unfractionated heparin
• warfarin


Methods of prophylaxis:

• Admission to hospital and bed rest

• Anticoagulant therapy (heparin and warfarin)
• Leg elevation
• Elastic compressive bandage from the toes to the upper thigh
• Patients with phlegmasia cerulea dolens need thrombolytic therapy
Medical treatment:

Venous thrombectomy:

Phlegmasia cerulea dolens with contraindication to thrombolytics

Inferior vena cava filter:

Recurrent thromboembolism despite adequate anticoagulation
Progressing thromboembolism despite adequate anticoagulation
Complication of anticoagulants
Contraindication to anticoagulants

Surgical treatment:

Dilated tortuous veins


5% of adult population

Equal gender prevalence

Family history
Introduction:
• Varicose Vein

Incompetence of the venous valves

Primary venous incompetence
Secondary venous incompetence

Pathology:

Unsightly appearance

Discomfort and aching at the end of the day
Ankle swelling towards the end of the day
Complications:
Itching and eczema
Lipodermatosclerosis
Venous ulceration
Clinical manifestations:

Venous Eczema (stasis dermatitis):

Lipodermatosclerosis:

Venous Ulcer:

On examination:
Great or small saphenous vein
• Incompetent saphenofemoral junction or incompetent perforators
Exclude DVT or deep vein incompetence

Usually diagnosed clinically

Investigations done to confirm and exclude
• Duplex ultrasound
• Venography
• Abdominal and/or pelvic imaging
Investigations:


• Reassurance
• Elastic compression stockings
• Avoid prolong standing and change of occupation may be required
• Periodic elevation of the feet
Treatment:
• I- Conservative Treatment:

Sodium tetradecyl sulfate (STD)

II- Injection sclerotherapy:

Indications for surgery:

Symptomatic varicose veins
Complicated or bleeding varicose veins
Large varicose veins
Cosmetic purposes
Surgical options include:
Ligation and stripping of the saphenous vein
Multiple subfacial perforator ligation
Combination of both.
Complications of varicose vein surgery:
Nerve injury (saphenous nerve and sural nerve)
Recurrence


III- Surgical Treatment:

Pathology:

• Deep Vein Incompetence

Leg swelling,

Discomfort on walking,
Edema,
Varicose veins (which may not be present),
Ankle flare (small varices),
Lipodermatosclerosis
Ulceration
Clinical presentation

Post Phlebetic syndrome:

• Duplex ultrasound
• Venography.
Investigations:

• Elastic compression stockings

• Avoid prolong standing and change of occupation may be required
• Periodic elevation of the feet
• Exercise of the calf muscles
Treatment:
• I- Conservative Treatment:

• Venous bypass procedures (e.g. Palma procedure)

• Venous valve reconstruction
• Venous valve transposition
II- Surgical Treatment:

Venous disease: deep vein incompetence

Arterial ischemia
Rheumatoid ulcer
Traumatic ulcer
Neuropathic ulcer (diabetic)
Neoplastic ulcer (squamous cell carcinoma and basal cell carcinoma).


Differential diagnosis of leg ulcers:
• Venous Ulceration

Not fully understood

Ambulatory venous hypertension
Due to valve incompetence:
Incompetent superficial veins
Incompetent perforator veins
Incompetent or obstructed deep veins
Etiolgy:

Site: gaiter region (between calf and ankle)

Size: usually large
Depth: usually superficial
Edges: gently sloping edges
Base: granulation tissue + slough and exudates
Discharge: pus occasionally blood
Surrounding tissue: features of chronic venous disease
Local lymph nodes: enlarged (superadded infection)
Movement of ankle joint: restricted due to pain
Clinical examination

Venous Ulcer:

• Swab and culture from the ulcer
• Duplex ultrasound
• Venography
Investigations:

multilayered elastic compression bandaging system,

avoid prolong standing,
periodic leg elevation
Treatment:
• I- conservative Treatment:



• Surgery for the cause of the venous ulcer (varicose vein, DVT or chronic venous insufficiency)
• Perforator vein subfacial ligation
• Skin graft to the ulcer after dealing with the underlying cause
II- Surgical Treatment:


External trauma,
Venepunctures and infusions of hyperosmolar solutions and drugs.
Intravenous cannula
Some systemic diseases: buerger’s disease, and malignancy,
Coagulation disorders: polycythaemia, thrombocytosis and sickle cell disease

Etiology:

• Superficial Thrombophlebitis

• Treatment::

• Reassurance
• NSAIDs
• Warm massage

Superficial thrombophlebitis

Thank You